C H A P T E R 1 2

BIOLOGICAL PREPAREDNESS
AND RESPONSE
Adrian Crowe

LTHOUGH PUBLIC AWARENESS of the possible use of

A biological agents in a terrorist event has risen since events such as

the anthrax attacks immediately following 9/11, its history is as
long as that of warfare.1 The use of biological agents includes
medieval siege tactics in which human bodies infected with plague were cata-
pulted over the walls of besieged cities, the assassination of Georgi Markov in
London in 1978 using a ricin pellet fired from an umbrella, and the deliberate
salmonella contamination of salad ingredients in Oregon in 1984 in the hope
of deterring voter turnout in a local election.2,3

OBJECTIVES:
ã Understand the characteristics of a biological event and how its impact on a hospital differs

ã
from that of a conventional mass-casualty event;

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Describe the methods of detecting a biological event and the potential triggers; and
Understand and describe the key aspects of biological agent preparedness and response for
a healthcare facility.

Terrorist attacks using biological agents can be difficult to detect and can
result in a larger and more sustained impact on healthcare facilities than that re-
sulting from a conventional, rapid-onset, short-duration mass-casualty event.
Although hospitals should be prepared for all hazards, there are specific pre-
paredness and response measures for dealing with patients exposed to biological
agents that must be incorporated into preparedness planning. For instance, the
plan should detail procedures for stockpiling supplies, establishing screening cen-
ters and alternate care sites, providing decontamination areas and supplies, and
altering staffing patterns to compensate for decreased numbers of available staff.

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BIOLOGICAL AGENTS
Categories
Biological agents are toxins that can cause illness or death in exposed hu-mans
or animals. The US Centers for Disease Control and Prevention (CDC) pri-
oritizes and assigns potential bioterrorism agents into categories A, B, or C,
according to their ease of transmission and severity of effects.4
Category A agents include those biological agents that are disseminated or
transmitted easily from person to person, have a high mortality rate and the
potential for a major public health impact, may cause public panic and social
disruption, and may require special preparedness activities. Agents in this cat-
egory include anthrax, botulism, plague, smallpox, tularaemia, and hemor-
rhagic fever viruses, such as Marburg, Ebola, Lassa, and Machupo.
Category B agents include agents that are moderately easy to disseminate,
cause moderate morbidity and low mortality, and require enhanced diagnos-
tic surveillance capabilities. These agents include brucellosis, epsilon toxin of
Clostridium perfringens, organisms that threaten food safety (e.g., salmonella
and E. coli 157), glanders, melioidosis, psittacosis, Q fever, ricin, staphylococ-
cal enterotoxin B, typhus, alphaviruses, and agents that threaten water safety
(e.g., Vibrio cholerae and Cryptosporidium parvum).
Category C agents include the viruses of emerging diseases, such as the
Nipah virus and the hantavirus, which pose a potential risk due to their abil-
ity to be engineered and produced for mass dissemination, and their ability to
cause high morbidity and mortality rates.
An overview of potential biological agents is provided in Appendix 12A.

Specific Agents
The following biological agents are of particular concern due to their ease of
transmission and associated potentially high fatality rates.
Anthrax (bacillus anthracis) is a large spore-forming, gram-positive rod, capa-
ble of causing three different clinical manifestations.
Cutaneous anthrax follows direct exposure to spores from sick animals or
from the contaminated wool or hides of sick animals. Within one day following
exposure, localized itching may occur. This develops into a pustule of central
coagulation necrosis surrounded by vesicles within one to seven days after expo-
sure. The lesion further develops into a black eschar with surrounding edema.
Bacteremia and lymphatic spread via liver, spleen, and kidneys also may occur;
Pulmonary or inhalational anthrax occurs within one to three days after
anthrax spore inhalation. Macrophage ingestion in the alveoli results in hemor-
rhagic mediastinitis and pulmonary edema, with hemorrhagic pleural effusions.
Initially, victims often have non-specific symptoms (cough, fever, and fatigue) and
substernal discomfort. They may experience a temporary period of improvement

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followed by catastrophic deterioration with severe chest pain. Thoracic imaging

demonstrates a widened mediastinum and, in some instances, pleural effusion.
Intestinal anthrax occurs as a result of ingestion of anthrax-contaminated
meat or dairy products. Victims develop nausea, vomiting, and fever within
1–7 days of ingestion. Acute abdominal pain with rebound tenderness and
ascites also may occur.
Botulism is caused by the neurotoxins in Clostridium botulinum, gram-
positive, spore-forming anaerobes. It can manifest in several ways.
Food-borne botulism occurs through the ingestion of pre-formed toxin
(usually in canned or preserved foods).
Wound botulism is a wound infection that occurs following trauma or
surgery, subcutaneous heroin injection, or cocaine snorting, in which toxin
from wound colonies spreads systemically.
Intestinal botulism occurs through ingestion of the bacteria found in dirt
and dust. It can occur in infants whose immature digestive systems make
them especially vulnerable, and in older children and adults who have had
bowel surgery or who have intestinal conditions, such as colitis.
Inhalational botulism does not occur naturally, but has potential as a bioter-
rorist agent when the toxin is aerosolized. To date, inhalational botulism has
occurred only accidentally in three veterinary laboratory workers in 1969.5
All forms of botulism exposure cause symptoms within six hours to two
weeks of exposure, initially affecting the cranial nerves (causing blurred
vision, drooping eyelids, and difficulty swallowing) with development of
progressive, symmetric, descending motor weakness and a descending flaccid
paralysis. Sensation and level of consciousness remain intact.
Plague (Yersinia pestis) is a facultative, anaerobic, intracellular, gram-nega-
tive bacillus. Generally, it is transmitted via a vector (flea) bite, but aerosolization
causing an inhalation infection is possible. Plague takes three forms.
Bubonic plague occurs following skin deposition from a plague-infected
vector causing lymphoid invasion and vascular seeding with septicaemia.
Pneumonic plague occurs following direct inhalation of the bacillus and
causes multilobar bronchopneumonia with septicaemia.
Primary septicaemia occurs following direct deposition of the bacillus
into the vascular system resulting in sepsis without buboes.
All forms of the plague tend to present similarly after one to six days of the
bacillus incubation period, with general malaise and pyrexia, abdominal pain,
vomiting, constipation, and diarrhea (particularly in the septicaemia form),
cough, and shortness of breath. If present, buboes generally are inguinal, axil-
lary, cervical, or epitrochlear. Disseminated intravascular coagulation can result
in purpuric lesions, ecchymoses, and digital necrosis, as well as haematemsis,
haemoptysis, and melena.

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Smallpox (variola) is an orthopox virus that is transmitted from person to

person. It invades the respiratory epithelial cells, replicates, then spreads hema-
togenously (after 72–96 hours) to the skin, lungs, kidneys, gastrointestinal tract,
and brain, with associated pyrexia, myalgias, headache, and delirium.
The incubation period lasts seven to 17 days, during which time victims are
not contagious. In classic variola major, skin invasion causes a maculopapular
rash that becomes pustular, initially in the oral mucosa and, then, spreading to
the forearms, hands, lower limbs, and trunk. In turn, these pustules progress
through macule, papule, vesicle, and umbilicated papule stages before forming
a crust and scab. All lesions on the victim’s body develop at the same stage of
progression. The cutaneous scabs usually fall off 3 weeks after development of
the rash; and the patient remains contagious until all scabs have fallen off.
Other presentations of the virus may include: (1) hemorrhagic smallpox,
which is characterised by hemorrhagic macules and is rapidly fatal; (2) flat
smallpox, with velvety skin lesions and an associated 95–100% mortality rate;
and (3) alastrim smallpox (variola minor) with lesions that appear similar to
variola major but are fewer in number and less florid in appearance.
Tularemia (Francisella tularensis) is an aerobic, gram-negative, pleomorphic
bacillus carried predominantly by ticks, deer flies, horse flies, rabbits and, in-
creasingly, by domestic cats. It can occur in six forms:
Ulceroglandular tularaemia occurs following entry through the skin
(usually via a tick or insect bite). The development of a papule occurs on the
hands or fingers, after three to five days of incubation, and is associated with
painful lymphadenopathy, ulceration and pyrexia.
Glandular tularemia occurs in the same manner as ulceroglandular and pres-
ents similarly with regional lymphadenitis, but with no primary skin lesions.
Oculoglandular tularemia occurs after conjunctival inoculation and pres-
ents with purulent conjunctivitis and ipsilateral lympadenopathy.
Oropharyngeal tularemia is rare and follows ingestion of bacillus-infected
animal meat or contaminated food and water, and presents with gastrointesti-
nal symptoms and a sore throat.
Pneumonic tularemia follows inhalation exposure to the aerosolized bacil-
lus. It presents with cough, dyspnea, and chest pain, with multilobular infil-
trates or pneumonia that may progress to acute respiratory distress syndrome
and respiratory failure.
Typhoidal (septicemic) tularemia is a typhoid-like condition that follows
bacteremia with symptoms of pyrexia, myalgia, and malaise.
Viral hemorrhagic fevers (VHF) are a group of illnesses caused by arenaviridae
(e.g., Lassa fever, which is spread by rodents), bunyaviridae (e.g., Hantavirus, spread
by rodents and Crimean-Congo fever, spread by ticks), filoviridae (e.g., Marburg and
Ebola), and flaviviridae (Yellow fever and dengue, which are spread by the mosquito).

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VHE can be spread through direct contact with an infected person or

through contact with their body fluids. Initial signs and symptoms include
fever and weakness. Symptoms of increased vascular permeability develop,
including hemorrhage, shock, coma, and multi-organ failure.
Ricin is a biotoxin produced naturally by the castor plant (Ricinus communis)
that inhibits intracellular protein synthesis. Exposure can occur via four routes:
Dermal exposure, which presents a low risk as transdermal absorption is
insignificant.
Gastrointestinal exposure occurs with exposure to large amounts of ricin, as its
absorption is poor. Gastroenteritis and gastrointestinal hemorrhage may occur.
Parenteral exposure often is rapidly fatal, with severe gastroenteritis and
pyrexia.
Aerosol or inhalational exposure often causes fever, cough, and pulmonary
edema within a few hours, and can progress to severe respiratory distress and
death in 36–72 hours of exposure. Other potential symptoms include cyano-
sis, diaphoresis, weakness, and bronchoconstriction.
All routes of ricin exposure may produce vomiting, diarrhea, dehydra-
tion, hypovolemia, and shock.

BIOLOGICAL EVENTS
Characteristics
Exposure to biological agents may occur through inhalation, oral, or dermal
routes. An aerosolized delivery allows the greatest dispersal of the agent, which
could make it a terrorist’s route of choice. Contamination of food and/or water
supplies also is a feasible method of delivery that carries a high rate of disper-
sal.6 Prime agents for terrorism would be those with high infectivity rates and a
prolonged period of effectiveness, such as anthrax, plague, and smallpox.
Because of the delayed onset of symptoms, victims, healthcare staff, and
government authorities initially may be unaware that a bioagent exposure has
occurred. Unless there was an announcement by a terrorist group at the time
of the event, it is unlikely that victims would know immediately that they had
been exposed, and they would not begin to seek care until they became symp-
tomatic within the ensuing days or weeks. Because of the generalized nature
of the symptoms produced by these agents, an accurate diagnosis may not be
made of the initial victims seeking care, thereby causing further delays in rec-
ognizing the occurrence of a bioterrorist event.
As the number of symptomatic victims increases, so will the demands placed
on the healthcare system. For instance, during the peak of the Severe Acute
Respiratory Syndrome (SARS) epidemic in Taiwan, 15 to 25 patients with SARS
were admitted each day over a four-week period.7 In addition to the impact on

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available hospital beds and equipment, (such as ventilators, masks, and gowns),
biological events impact the staff, some of whom may become symptomatic and
unable to work, and some of whom may elect not to come to work.
Once a biological event has been recognized, large numbers of people
who have not been exposed but may be concerned for their health also may
present to the healthcare facility with symptoms (e.g., sweating and tachycar-
dia) similar to those of infected patients. These patients often are referred to
as the “worried well”. These patients need comfort measures rather than
medical treatment. Differentiating the “worried well” individuals from the
truly infected individuals is difficult and likely to require the capacity for
mass physiological screening with a rapid turnaround of diagnostic testing
results in order to provide reassurance and epidemiological monitoring. Some
biological incidents have resulted in the presentation of hundreds of patients
with a psychogenic phenomenon, sometimes referred to as “gas mania”, a
name that originated in the trenches of the First World War.8

Detection
The occurrence of bioterrorism may be detected by an astute clinician in a sen-
tinel case, by unexplained changes in admission patterns to a hospital or critical
care unit, or by formal syndromic surveillance.9 However, in order for a sentinel
case to be diagnosed, healthcare providers must have adequate background
knowledge of potential bioterrorist agents and a high index of suspicion. The
routine triaging of patients should include gathering information on recent trav-
el, domestic situation and place of habitation, work patterns, attendance at spe-
cial events (such as sports events or other mass gatherings), and contact with
domestic or wild animals.10 These routine questions may be modified and/or
added to, based on the knowledge of a current event (e.g., questions regarding
travel to Hong Kong or Toronto, Canada, during the SARS outbreak).
There are a number of signals or triggers that should prompt considera-
tion of a bioterrorism event. These include the occurrence of:
1. A rapid rise and fall in the occurrence of a particular disease/
syndrome (the epidemic curve);
2. A steady increase in the number of cases presenting with a
particular disease/syndrome;
3. A disproportionate number of patients with similar symptoms;
4. A disproportionate number of patients from the same locality
or venue;
5. A large number of rapidly fatal cases;
6. A disproportionate occurrence of illness in patients who were
outdoors as compared with those who were indoors;
7. The presentation of patients with symptoms of an uncommon

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disease (e.g., anthrax or plague); and

8. An associated widespread increase in the number of animal
deaths.6
As laboratory investigation and confirmation likely will be required for many
biological agents, acute care facilities should have standing arrangements with ap-
propriate laboratories to provide this service on a 24-hour basis. In the United
States, the CDC, through the establishment of the Laboratory Response Network
(LRN), has increased the number of Biosafety Level 3 (BSL-3) state laboratories
capable of rapid testing for biological threat agents. In the United Kingdom, the
national response framework is structured around Health Protection Agency lab-
oratories. As samples sent to these laboratories may need to be collected and
processed in a specific manner, stocks of necessary products (e.g., transport media
and personal protective equipment [PPE]) should be available readily to staff
responsible for and familiar with their use.10
Healthcare facilities should participate in local, regional, and/or national
syndromic surveillance networks, which can facilitate early identification of an
epidemic curve and, in turn, can provide an information cascade to raise staff
awareness of particular syndromes in a “just-in-time” manner.11 Staff familiar-
ity with the use and purpose of these surveillance networks should be rein-
forced on a regular basis in order to ensure efficient information flow during
times of crisis.

HEALTHCARE FACILITY PREPAREDNESS

Procedures and Policies
During a biological event, the staffing patterns of a healthcare facility must be
adjusted to accommodate the increasing number of patients presenting to the facil-
ity, as well as the number of staff members who elect not to or are unable to report
to work. Studies have demonstrated that the number of staff who report to work
during such an event can be anticipated to be between 50–70% of the regular staff
level.12 Some solutions to the increased staffing needs include extending shifts,
housing staff at the facility, providing on-site child and pet care, and increasing the
patient/nurse ratio. However, these procedures must be determined and communi-
cated before the event to ensure that the staff is aware of the policies and to ensure
that there are no gaps in the provision of staffing during the event.
Each institution must establish plans for two-way information exchange
with local public health authorities. These reporting systems for actual or sus-
pected bioterrorist events and other infectious diseases should be available read-
ily to all appropriate staff on a 24-hour basis. Equally important is the reliable
dissemination of information from pre-arranged central distribution points to all
healthcare facilities; this was a weak point in the response to anthrax-laden let-

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ters in 2001.12 In the United States, the CDC’s Health Alert Network (HAN) is
one such point of distribution; it provides immediate dissemination of informa-
tion related to health threats to local and national health officials. However, one
study found that only 54% of US hospitals surveyed had an established link to
HAN, and that only 40% had 24-hour access to a contact within their local
health department.13 In the United Kingdom, information is cascaded through
the Health Protection Agency and local Primary Care Trust; reporting systems
for actual or potential bioterrorist events occurs through a local lead Primary
Care Trust via a regional Strategic Health Authority to the central government.
Additionally, when a number of healthcare facilities are involved in a bioagent
response, real-time cross-facility reporting of patient load and resource availabil-
ity becomes essential.14 This may represent a significant cultural shift among
hospitals that normally are in competition with each other. Therefore, such
cooperative links must be established before any event occurs.
Policy-makers at acute care institutions must recognize that a biological
event could overwhelm their resources and, in all likelihood, those of the
neighboring facilities. Although the concept of triage is likely to be less alien
to staff in the ED than elsewhere in the organization, the shift in healthcare
focus to “the greatest good for the greatest number” may be uncomfortable
for some, and decisions about the criteria for offering only palliative care to
unsalvageable patients should be made in advance and supported by written
institutional policy.15 Some authorities have proposed alternative triage sys-
tems for mass-casualty biological events, in which evidence of a toxic syn-
drome in an ambulatory, or non-ambulatory but alert, patient upgrades their
triage category and the antidote is administered quickly, if available, for that
particular agent.16 If such a triage system is to be used, the criteria and process
used to guide decision-making must be clarified in advance to protect and
support the staff tasked with making those decisions.
Preparedness plans also should include the provision of care for the staff;
that is, there should be plans in place for the acquisition and distribution of vac-
cines or antibiotics, prophylactically, to staff and, if necessary, their families.17
Support staff from health departments or public health who are not involved in
providing acute patient care should be tasked with undertaking this activity
during a biological event.

Equipment
Healthcare facilities either must have their own equipment stockpiles or have
rapid access to community stockpiles of the equipment required to respond
to a biological event. This must include sufficient stockpiles of items to pro-
tect staff and prevent the spread of disease, as well as those additional items
needed to provide patient care.

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PPE for staff who may be exposed to toxins or infectious agents is essen-
tial. When the known or suspected infectious agent is transmitted by airborne
droplet nuclei (e.g., smallpox or plague), the victim should be placed in a neg-
ative pressure room with High Efficiency Particulate Air (HEPA) filtration, if
possible, and care providers should wear, at the least, an N95 respirator (in
Europe this correlates roughly to an FFP2 or FFP3 mask).18 Staff require pre-
event training and practice, both in donning of the PPE and in providing care
while wearing it. Based on the length and magnitude of the event, the supply
of the appropriate protective masks may become depleted, even with support
from government stockpiles. This occurred in Hong Kong during the SARS
epidemic.19 The US Occupational Safety and Health Administration (OSHA)
advises that the reuse of N95 masks may be considered if supplies are deplet-
ed and the masks are not obviously soiled.20
Recommendations for the quantities of masks and other PPE that must be
stockpiled by hospitals and the community vary. National or federal stockpiles
of equipment and consumables (in the form of “push packages” in the United
States,9 and “pods” in the United Kingdom) may be made available to health-
care facilities within hours to days. Institutional preparedness plans must take
into account local variation in stockpile availability and the estimated time for
delivery. Unfortunately, generic stockpiles may not be well-suited to an inci-
dent that disproportionately affects a particular special population, such as the
elderly or children.21
During certain biological events, medical equipment, such as ventilators,
may be in short supply. Within the US hospital system, there are a total of
105,000 ventilators, while estimated ventilator requirements during a flu pan-
demic are projected to be approximately 742,500.12 The US Strategic National
Stockpile contains approximately 5,000 ventilators, well below the projected
needs in a widespread biological event. Pre-arranged agreements between
hospitals and area vendors may help supplement the number of ventilators
available. The utilization of older ventilators or the conversion of anesthesia
machines for ventilator use also may supplement the supply. With a probable
shortage of ventilators during a large-scale event, healthcare leadership must
consider the potential development of a ventilator triage process that would
guide medical staff in determining which patients are provided with a venti-
lator and which are not. Application of the Sequential Organ Failure Assess-
ment Score (Appendix 12B) provides an option for ethically defensible
triage.22

Alternate Treatment Sites

Alternate treatment sites have been identified as a means of providing surge
capacity for mass-casualty incidents. In a biological event, these sites would

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be set up as direct patient care sites as well as a means for increasing available
isolation bed space.
An alternate treatment site may be set up at a pre-established location and
can utilize an existing building, tent, or mobile structure. It can be operated with
staff support and supplies from public health departments, area hospitals, and
local emergency management agencies through pre-established agreements.
The US Department of Health and Human Services recommends that po-
tential alternative care sites be assessed for their ability to provide the following:23
1. Increased bed capacity and separation of patients;
2. Hygiene and shower facilities;
3. Food services;
4. Sufficient capacity for storage of PPE, supplies, and linen; and
5. Safety and security.
Hospitals also must identify areas within their own buildings that can be con-
verted into patient care areas. These alternate care areas address the surge of increas-
ing admissions by providing additional spaces within the facility to care for the
patients. Establishing alternate care areas may involve converting the function of a
well-supplied area, such as a surgical recovery area, to a receiving area for admitted
patients; or it may involve transforming a non-patient care area, such as a cafeteria
or waiting room, into an area being used for patient care. Plans must not only iden-
tify space, but also detail the procedures for obtaining needed supplies and staff.
Ideally, patients with infectious diseases transmitted via the airborne route
should be placed in a private, negatively-pressurized room with HEPA filtration,
which removes almost all of the airborne particles. Medical-use HEPA filtration
also incorporates high-energy ultraviolet light to kill any live bacteria or viruses
collected by the filter. However, most healthcare facilities have a limited number
of negative-pressure rooms sufficient for the needs of a bioterrorism event. On the
assumption that all of the victims of a particular biological event have been
exposed to the same agent, it would be reasonable for facilities to plan for the
placement of these patients in shared rooms, i.e., cohorts, ideally with a ventilation
supply that is separate from the non-infected areas of the hospital.24
Large-scale biological incidents may require that infected patients be grouped
together on entire floors/wards or, in extreme circumstances, entire wings or
buildings of the institution. To limit the number of staff working in these isolation
areas, it may be advisable for staff to work alternating 12-hour shifts and to be
housed at the hospital. Seeking volunteers for this assignment, offering bonuses, or
seeking those who have had the necessary vaccination (based on the agent) are
some methods that may be useful in providing staff in these areas.

Screening Centers
Screening centers, or “fever clinics”, as were established in both Hong Kong and

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Toronto during the SARS outbreak, can serve as externally located triage facilities.
Such centers may be located immediately outside of the hospital or located else-
where in the community through coordination by public health departments.
These centers can help to reduce overcrowding in the EDs and, by virtue of the
increased space, may decrease the risk of transmission during patient assessments
by providing sufficient space between each patient. When some hospitals in
Toronto were closed by the Public Health Department because of the spread of
SARS, establishing screening centers outside of the hospital increased the ability of
the hospital to continue functioning throughout the event.25
The establishment of screening centers requires a well-planned strategy for
providing consistent information from public health officials for those patients
sent home from the center. This is essential to promote compliance with any re-
quired home care or home quarantine, and, in turn, for ensuring needed patient
information is properly documented and forwarded to Public Health services.

ANTHRAX PROPHYLAXIS CLINIC

In late October 2001, four postal workers from a mail processing center in Washington, DC
were hospitalized from inhalational anthrax; two ultimately died. The US Public Health
Service (USPHS) established a temporary anthrax prophylaxis clinic at DC General Hospital
to receive other potentially exposed persons from the postal centers. The clinic operated 14
hours/day for a period of 14 days, and over that time dispensed medication to 18,051 persons.
Individual patient processing time varied from 20 to 55 minutes. Patients initially completed a
questionnaire and then, in groups of 50, listened to a presentation on anthrax by a physician
and a pharmacist. This was followed by a question-and-answer period. All patients received
a 10-day supply of appropriate antimicrobial medications. This allowed sufficient time to test
all potentially exposed postal center employees and to determine who would need the full
60-day treatment regimen.46
Robert Powers

HEALTHCARE FACILITY RESPONSE

Implementation
Implementation of a healthcare facility’s response plan begins either with
recognition by trained staff members of potentially exposed, arriving victims,
or through notification from a public health entity. Staff should be trained in
the use of, and have immediate access to, the necessary PPE. Suspected victims
should be masked and removed immediately from the waiting room to an iso-
lation room with negative pressure capability. As learned in Toronto during
the SARS epidemic, victims quickly can spread airborne diseases in crowded
waiting rooms or EDs.26 Unless immediate triage can be performed, screening

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of potentially infected victims outside of the hospital building, or the masking

of all patients until triage is performed, may be appropriate containment
strategies. Given the likely problems with supplies of masks, the former
method is preferable.
The overall hospital response to a bioterrorism incident should mirror the in-
stitution’s response to a non-biological MCI as closely as possible. The hospital
should implement its incident command structure (e.g., Hospital Incident Com-
mand System27 or the UK Medallion System, which utilizes Gold, Silver and
Bronze levels to correspond to strategical, tactical, and operational command)28
to: (1) coordinate the response and communications with other agencies; (2)
expand facilities and staffing; (3) manage multiple patients; (4) care for the
patients’ relatives; and (5) provide robust media management. Regulated and reli-
able information flow to the media may reduce the likelihood of covert media
activity with its attendant risk of infection spread.29
Hospital lockdown, i.e., securing all portals of entry, may be necessary to
prevent the contamination of inpatient areas.17 Incoming patients should be
routed around the hospital to the identified, appropriate entry point (e.g., the
designated ED entrance or the screening center). This requires allocating
security staff to enforce these closures and erecting clear signage to redirect
patients and visitors to the appropriate entrance.
It is likely that the care and management of patients with specific biological
syndromes will be provided by healthcare professionals who are inexperienced
with such diseases. Of US anesthesiology resident programs surveyed, only
37% included training in the management of the effects of chemical and biolog-
ical weaponry.30 Therefore, healthcare facilities must ensure that easy and reli-
able access to biological information is available readily for up-to-date guidelines
regarding patient management. In a large-scale event, this information may be
provided to the hospital through systems such as the CDC’s HAN in the United
States, and the Health Protection Agency in the United Kingdom. Public health
Websites also provide regularly updated treatment information about specific
biological agents. Hospital infection control staff also should ensure that there
are easily-accessed hard copies of the latest biological agent information on hand
in case of complications with the computer system during an event.
Additionally, the hospital should ensure distribution of information to all staff
during the event, detailing the measures they need to take for personal protec-
tion (e.g., N95 mask usage).

Decontamination
Decontamination procedures for a biological event likely will not be necessary. As
most patients do not proceed to the hospital until they become symptomatic, (i.e.,
days to weeks after their exposure), they will have self-decontaminated at home by

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showering and changing clothes multiple times within that time period.
A notable exception would be a terrorist event that was announced to the
media as it was happening or shortly thereafter. When victims become aware
of the event through such an announcement, they likely will proceed to the
nearest hospital for care, and likely will not have had sufficient time to self-
decontaminate at home. These individuals will require outside decontamina-
tion prior to entry into the healthcare facility.
However, because not all biological agents are transmitted through direct
contact, only exposure to those agents (plague, viral hemorrhagic fevers, or ricin
toxin) that spread through direct contact would require that victims undergo
decontamination procedures beyond removal of contaminated clothing.

Sustainability
Sustaining healthcare facility operations is likely one of the most important chal-
lenges during a bioterrorism response. Unlike conventional terrorist activity (for
example the London bombings in July 2005, when EDs resumed normal func-
tionality within six to eight hours),31 presentations of victims of bioterrorist
events may occur over ensuing days or even weeks, and the care and management
of infected patients is likely to extend for several weeks.
Unless an attack is geographically limited, affected healthcare facilities are
unlikely to be able to utilize mutual aid agreements to transfer patients to other
facilities for care as all hospital facilities will be overwhelmed.32 Additionally, to
limit contamination, hospitals may be prevented from transferring exposed pa-
tients. This occurred in Toronto when public health officials prevented Toronto
hospitals from transferring SARS-infected patients to other hospitals. Thus, hos-
pitals must plan on providing care for patients through the utilization of stock-
piles, alternate care sites within the hospital, and altered staffing patterns.
A widespread biological attack with a prolonged effect may impair the eco-
nomic infrastructure of the community to the point that a facility’s supply chain is
compromised and no longer functional.6 Thus, in addition to having sufficient
stockpiles of PPE and treatment agents, (e.g., ciprofloxacin), hospitals need these
supplies to be close at hand so that they can be obtained readily without undue
dependency on transportation or other, potentially incapacitated, support services.
Implementing revised admission criteria and cancelling all elective surger-
ies are strategies used to free bed space. These steps also allow the utilization
of post-anesthesia care areas for alternative care sites. Supplies required for
the conversion of non-treatment areas of the hospital into treatment areas
should be identified before the event. Consideration should be given to the
ability to gather supplies quickly and detailed plans should include identifica-
tion of the key contact person and the criteria that will be used to provide the
“green light” for the readiness of the area to accept patients.

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INTERNATIONAL DISASTER NURSING

Hospitals also may need to handle a larger-than-usual number of fatalities

as a result of the disease process and the disruption of normal funeral prac-
tices; contingency arrangements must be in place for the management of large
numbers of potentially infectious bodies.17 Management options include
coordinating efforts with specialized response units, such as the US Disaster
Mortuary Operational Response Team (DMORT), or acquiring refrigerated
trucks from the local community for storing bodies.
In addition to changing standard staffing patterns, identified non-essential
staff members may be reassigned to essential roles. Staff confidence and will-
ingness to come to work also must be considered. Studies of hypothetical
SARS and smallpox outbreaks have identified that although 63% of hospital
staff indicate they would be willing to report to work during a SARS epidem-
ic, only 48% indicated they would be willing to attend to patients.33 Addi-
tionally, in the absence of a vaccine and PPE, only 4% of surveyed paramedics
indicated that they would report to work during a smallpox outbreak. The
provision of PPE alone would improve this response to only 37%.34 In a
recent study, Canadian nurses reported that they were inadequately equipped
and trained to work during an infectious outbreak, particularly one resulting
from an act of terrorism.35 Providing adequate stockpiles of PPE and increas-
ing staff confidence through training and exercise in the use of PPE would
increase the willingness of staff to provide care for patients of a biological
event. Indeed, 74% of nursing students identified personal protection as their
primary concern in the event of a disaster.36 Other studies of healthcare
providers have found low levels of necessary knowledge and confidence to
respond to bioterrorism events.37–39
The stress and associated dangers experienced by staff caring for the vic-
tims may necessitate psychological support for the staff. Hospital planning
must include the care and counselling needs of staff; each shift should begin
and end with opportunities for the staff to debrief with co-workers. This
should be supplemented by available psychiatric crisis management that may
be required for patients and the extended demand for bereavement coun-
selling that is likely to accompany mass fatalities.8,14
In the event that the demand for resources (particularly those involving
critical care) exceeds the supply, providing the usual practice of care may not be
sustainable. Staff duty patterns may need to be amended (e.g., a 12-hour, rather
than an eight-hour shift) for a limited period of time. Alternatively, non-
specialist staff may be deployed to specialist areas to work under the supervi-
sion of fewer specialist staff, as recommended by the Society of Critical Care
Medicine.32 At some point, it may become necessary to triage patients to ensure
that resources are directed towards those most likely to benefit, even to the
detriment of patients who under normal circumstances would receive all care

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and treatments. A number of systems have been suggested to optimise this

process,40,41 and the ethical issues surrounding such a situation have been dis-
cussed, particularly in the context of pandemic influenza planning.42,43 How-
ever, no agreement has been reached regarding which system should be used
and no system has been demonstrated to be effective or usable in conditions
such as those induced by a bioterrorist attack. These issues are complex and
potentially contentious, and should be addressed before any event by all facil-
ities and their ethics committees, preferably in conjunction with their local
communities.

CONCLUSION
Terrorist attacks using biological agents can strain a hospital’s ability to contin-
ue providing medical care throughout the duration of the event. Trained staff
and easily-implemented plans based on clearly defined criteria can protect the
hospital by providing the ability to rapidly identify potentially exposed victims
and taking steps to prevent the further spread of the biological agent. Clear pro-
cedures for expanding into alternative care sites or for opening screening centers
can facilitate the hospital’s response to an event. Stockpiles of PPE and medica-
tions, along with the means for obtaining additional critical care services, assure
that the hospital can sustain and extend its functional duration.

IN LATE 2002, THE UNITED STATES began the first phase of a smallpox
vaccination program to increase preparedness in the event of a smallpox attack. The plan
called for one-half million military personnel to be vaccinated along with an additional
approximately one-half million healthcare first responders, i.e., front-line workers in
emergency medical services, hospital EDs, and public health agencies. During 2003, smallpox
vaccinations were administered to 39,213 healthcare workers who volunteered to receive the
vaccine. Due to concerns about the expense of the program versus its priority, and concerns
over adverse reactions, the program ended without progressing to the planned second stage,
which would have vaccinated millions of other healthcare workers and the general public.47
By the end of 2003, there had been 97 reported serious complications, including myocardial
infarction, cardiomyopathy, seizures, Parkinson’s disease, and appendicitis, as well as three
deaths following the smallpox vaccination.48
Robert Powers

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40. Challen K, Bright J, Bentley A, Walter D: Physiological-social score (PMEWS) vs. CURB-65 to
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Appendix 12A: Bioterrorism agents44, 45 ( IV = intravenous; CT = computerized tomography; ELISA = enzyme-linked

immunosorbent assay; IM = intramuscular; PCR = polymerase chain reaction; CDC = Centers for Disease Control
and Prevention)

CATEGORY A AGENTS
Incubation Presentation Investigations Management PPE /Prophylaxis
Anthrax — Immediate Papular lesion Culture Ciprofloxacin Standard
cutaneous – 1 day that becomes or doxycycline precautions
vesicular for 60 days Avoid contact
Black eschar with wound
in 7–10 days

Anthrax — Usually <1 Initially non- Chest X-ray: Ciprofloxacin or Standard

inhalational week, up to specific mediastinal doxycycline IV, precautions
2 months malaise; widening, continued orally
high fever pleural effusion; for 60 days
and severe Culture blood,
respiratory pleural fluid,
distress 1–5 CSF
days later

Anthrax — 1–7 days Nausea, Abdominal CT: Ciprofloxacin or Standard

gastrointestinal vomiting, mesenteric doxycycline IV, precautions
bloody adenopathy continued orally
diarrhea, Chest X-ray: for 60 days
acute abdomen; mediastinal
Ascites and shock widening,
2–4 days later pleural effusion
Culture blood,
ascitic fluid

Anthrax — 1–7 days Pyrexia, Blood and throat Ciprofloxacin or Standard

oropharyngeal throat pain, cultures doxycycline IV, precautions
regional lym- continued orally
phadenopathy, for 60 days
tongue base
ulcers

Arenaviruses 5 – 6 days Pyrexia, malaise, Serum ELISA, Supportive care,

(Lassa, Junin bleeding, viral culture some role for
Machupo, adenopathy, ribavirin
Guanarito, conjunctivitis
Sabia)

Botulism 6 hours – Cranial Demonstration Antitoxin, Standard

10 days, neuropathies, of toxin in stool supportive care precautions
usually symmetrical or serum;
12–36 hours descending Culture blood,
paralysis stool

Ebola/ 2–9 days Pyrexia, malaise, Serum ELISA Serum ELISA

Marburg virus icterus, bleeding

Plague 1–6 days Pyrexia, Blood, tracheal Streptomycin IM Droplet precautions

weakness, washing culture or gentamicin IV Ciprofloxacin or
pneumonia doxycycline post-
exposure prophylaxis

Smallpox 7–17 days 2–4 day PCR (regulated Supportive Airborne precautions
prodrome of by CDC in US) Vaccination
pyrexia and available (up to 7
malaise; 4 days days post-exposure)
of vesicular
rash with
central inden-
tation; 15 days of
pustular rash
and scabbing

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Appendix 12A: Continued

CATEGORY A AGENTS
Incubation Presentation Investigations Management PPE /Prophylaxis
Tularemia 3–5 days General malaise, Culture sputum, Streptomycin IM Standard
(up to 14 days) cough, stool or gentamicin IV precautions
diarrhea, Ciprofloxacin Ciprofloxacin or
pneumonia or doxycyline oxycycline post-
orally for exposure
mass casualties prophylaxis

CATEGORY B AGENTS
Incubation Presentation Investigations Management PPE /Prophylaxis

Brucellosis 2–4 weeks Non-specific Isolation in Doxycycline Standard

malaise, clinical plus rifampicin precautions
meningitis, specimen or Doxycyline plus
endocarditis rising titres rifampicin
post-exposure
prophylaxis

Cholera <1–5 days Profuse Oral rehydration

watery
diarrhea
(can be mild or
asymptomatic)

Clostridium Unknown Non-cardiogenic Supportive care Unknown

perfringens pulmonary
Epsilon toxin edema

Crypto-
sporidium
parvum

Escherichia 2–8 days Bloody Culture stool Avoid antibiotics Standard

coli O157 diarrhea, and anti- precautions
abdominal pain, diarrheals;
hemolytic supportive care
uremic
syndrome

Glanders 1–5 days Acute localised Culture blood, Sulphonamides, Droplet precautions
infection, sputum, doxycycline, Possible trimetho-
septicemia, urine, skin ciprofloxacin prim-sulfameth-
acute pulmonary oxazole prophylaxis
infection,
chronic cutan-
eous infection

Melioidosis 2 days–years Acute localised Culture blood, Augmentin,

infection, sputum, tetracycline,
pulmonary urine, trimethoprim-
infection, Skin culture sulfamethoxazole
septicemia, Antibody titres
chronic
suppurative
infection

Psittacosis

Q fever 2–3 weeks Pyrexia, gen- Antibody Doxycycline Standard

(may be eral malaise, detection orally for precautions
shorter pneumonia, 15–21 days Doxycycline or
with large hepatitis, Quinolones tetracycline
exposure) endocarditis post-exposure
prophylaxis

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Appendix 12A: Continued

CATEGORY B AGENTS
Incubation Presentation Investigations Management PPE /Prophylaxis
Ricin toxin < 8 hours Respiratory No specific Early Standard
(inhalation) distress, testing decontamination precautions
< 6 hours vomiting, available Supportive care once patient is
(ingestion) bloody decontaminated
diarrhea,
renal failure,
hallucinations

Salmonellosis 12–72 hours Diarrhea, Culture stool Supportive care Standard precautions
abdominal Ampicillin,
pain, gentamicin,
pyrexia, trimethoprim,
septicemia ciprofloxacin in
septicemia

Shigella 1–2 days Diarrhea, Culture stool Standard precautions

abdominal
pain, pyrexia

Staphylococcal 1–4 hours Nausea, Serum and Supportive care Standard precautions
enterotoxin B vomiting, urine toxin
abdominal detection
pain, respiratory
distress
(inhalational
exposure)

Typhoid Pyrexia, Culture stool Ampicillin,

abdominal pain, and blood trimethoprim-
pain, rose- sulfametho-
coloured spots xazole,
ciprofloxacin

Typhus

Viral Pyrexia, Culture Supportive care Standard precautions

encephalitis malaise, spinal fluid
headache or PCR

CATEGORY C AGENTS
Incubation Presentation Investigations Management PPE / Prophylaxis

Hantavirus Prodrome, PCR Ribavirin Standard precautions

non-cardiogenic
pulmonary
edema or
oliguric renal
failure

Nipah virus 2 weeks Pyrexia, Culture spinal Supportive care Standard precautions
headache, fluid, urine,
vomiting, tracheal
hyporeflexia aspirate

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Appendix 12B: The Ontario System for triage to the critical care unit22 (SaO2 = oxygen saturation of arterial blood;
FiO2 = fractional inspired oxygen; SBP = systolic blood pressure; TBSA = total burn surface area; NYHA = New York
Heart Association; COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 second;
PaO2 = partial pressure of arterial oxygen; VC = vital capacity; TLC = total lung capacity; RAP = right atrial pressure;
PAP = pulmonary artery pressure; SOFA = sequential organ failure assessment)
INCLUSION
The Presence of Either of the Following Two Conditions:
1. Requirement for invasive ventilatory support:
a. Refractory hypoxemia (SaO2 <90% on non-rebreathe mask/FiO2 >85%);
b. Respiratory acidosis (pH <7.2);
c. Clinical evidence of impending respiratory failure; or
d. Inability to protect/maintain airway
2. Hypotension (SBP <90 mmHg, or relative) with evidence of shock (altered consciousness, decreased urine
output, other end-organ failure) unresponsive to fluids and requiring inotropic or vasopressor support.

EXCLUSION
The Presence of Any of the Following Conditions:
1. Severe trauma;
2. Severe burns with either age >60 years, or >40% TBSA, or inhalation injury;
3. Cardiac arrest, either unwitnessed, or unresponsive to defibrillation/pacing, or recurrent;
4. Severe baseline cognitive impairment;
5. Advanced untreatable neuromuscular disease;
6. Metastatic malignant disease;
7. Advanced and irreversible immunocompromised condition;
8. Severe and irreversible neurological event or condition;
9. End-stage organ failure:
a. NYHA class III/IV heart failure;
b. COPD with FEV1 <25%, baseline PaO2 <55mmHg, or pulmonary hypertension;
c. Cystic fibrosis with post-bronchodilator FEV1 <30%, or baseline PaO2 <55 mmHg;
d. Pulmonary fibrosis with VC or TLC <60%, baseline PaO2 <55 mmHg, or pulmonary
hypertension;
e. Primary pulmonary hypertension with NYHA class III/IV heart failure, mean RAP >10mmHg, or mean
PAP >50mmHg; and
f. Child-Pugh score >7;
10. Age >85 years; or
11. Elective palliative surgery.

INITIAL ASSESSMENT

Triage Criteria Action /Priority

Blue Exclusion criteria met or SOFA >11 Medical/palliative management

Discharge from critical care unit

Red SOFA <7 or single-organ failure Highest priority

Yellow SOFA 8–11 Intermediate priority

Green No significant organ failure Defer/discharge

Reassess as needed

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INTERNATIONAL DISASTER NURSING

48-HOUR ASSESSMENT

Triage Criteria Action /P riority

Blue Exclusion criteria met, or SOFA >11 Palliative care
or SOFA 8–11 and stable Discharge from critical care unit
Red SOFA <11 and decreasing Highest priority
Yellow SOFA <8 stable Intermediate priority
Green No longer ventilator-dependent Discharge from critical care unit

120-HOUR ASSESSMENT

Triage Criteria Action /P riority

Blue Exclusion criteria met or SOFA >11 Palliative care
or SOFA <8 stable Discharge from critical care unit
Red SOFA <11 decreasing progressively Highest priority
Yellow SOFA <8 with <3-point decrease Intermediate priority
in 72 hours
Green No longer ventilator dependent Discharge from critical care unit

220